Title Is living with psychosis demoralizing? Insight, self-stigma and clinical outcome among people with schizophrenia across one year Running title Is living with psychosis demoralizing? Authors

Background: Lack of insight is a major target in the treatment of schizophrenia. However, insight may have undesirable effects on self-concept and motivation that can hinder recovery. This study aimed to examine the link between insight, self-stigma and demoralization as predictors of symptoms and functioning. Methods: Insight, self-stigma, depressive and psychotic symptoms, and functioning were assessed among 133 outpatients with schizophrenia at baseline and twelve months later. The data were analyzed by hierarchical multiple linear regressions. Results: More insight at baseline and an increase in self-stigma over twelve months predicted more demoralization at follow-up. Insight at baseline was not associated with any outcome variable, but self-stigma at baseline was related to poorer functioning and more positive symptoms at follow-up. More demoralization at baseline predicted poorer functioning twelve months later. Demoralization did not mediate the relationship between self-stigma at baseline and functioning after one year. Discussion: Given the decisive role of self-stigma regarding recovery from schizophrenia, dysfunctional beliefs related to illness and the self should be addressed in treatment. Different psychotherapeutical approaches are discussed.